A traumatic brain injury (TBI) is an injury that affects how the brain works. It happens when a sudden blow, bump, jolt or penetrating injury damages brain tissue. TBIs range from mild to severe, and symptoms vary person to person depending on the level of injury.
In this article
- What makes TBI different from other brain injuries
- Common causes of TBI
- How a TBI is diagnosed
- Levels of TBI: mild, moderate and severe
- Symptoms to watch for
- Who has a higher risk for TBI
- Effects and complications
- Recovery and possible timelines
- How inpatient rehabilitation helps
- Tips and support for caregivers
How does TBI differ from other brain injuries?
A traumatic brain injury (TBI) is different from other types of brain injuries because it is caused by an external force — someone hitting the head hard enough to affect the brain’s function. Non-traumatic brain injuries happen because of internal medical events, not external trauma.
Dr. Gilbert Siu, a rehabilitation physician at Encompass Health Rehabilitation Hospital of Vineland, explains it this way:
"Traumatic brain injury is generally due to external force impacting the brain, such as a car accident, fall, gunshot or concussion, while a non-traumatic brain injury is an internal force affecting the brain.”
Examples of non-traumatic brain injury include stroke, infections, COVID-19 and brain cancer.
What causes TBI?
According to the Centers for Disease Control and Prevention (CDC), the most common causes of TBI are:
- Falls
- Firearm-related injuries
- Motor vehicle accidents
Other causes can include:
- Sports-related injuries
- Domestic violence
- Combat injuries
- Explosions
How is TBI diagnosed?
To diagnose a TBI, clinicians determine the type and severity of the injury. There are several technologies and tools used to evaluate suspected TBI.
Questions a clinician may ask:
- How did the injury happen?
- Did the person lose consciousness? If so, how long?
- Did you notice changes in alertness, speaking, coordination or behavior?
- Where on the head or body did the impact occur?
- What was the force like? (e.g., what hit their head, how far did they fall or was the person thrown from a vehicle?)
- Was the person thrown, shaken or severely jarred?
Image tests used for TBI
Clinicians often use imaging tests in the case of suspected TBI to take a thorough look at the brain.
- Computerized tomography (CT) scan: Uses X-rays to create a detailed view of the brain. A CT scan can quickly detect:
- Skull fractures
- Brain bleeding (hemorrhage)
- Blood clots (hematomas)
- Bruised brain tissue (contusions)
- Swelling of brain tissue
- Magnetic resonance imaging (MRI): Uses radio waves and magnets to create detailed images. This test may be used after the person's condition stabilizes or if symptoms don't improve soon after the injury.
Types of brain injury scales
Glasgow Coma Scale (GCS)
Clinicians use an assessment called the Glasgow Coma Scale (GCS) to determine how severe a TBI is. According to the Brain Injury Institute, the GCS assigns numbers to eye, verbal and motor responsiveness. Each area is scored and added together for a total GCS number between 1 and 15. The lower the number, the more severe the injury.
Rancho brain injury scale
The Rancho brain injury scale, also known as the Rancho Los Amigos Scale (RLAS), is a 10-level framework used to observe and evaluate potential brain injuries. Rehabilitation teams assess cognitive and behavioral patterns and assign it to a level on the scale.
What are the levels of TBI?
TBIs are generally grouped into mild, moderate and severe, based on loss of consciousness, symptoms and imaging findings.
Mild
- GCS score: 13-15
- May or may not lose consciousness; if they do, it lasts under 15 minutes
- Memory loss is temporary and returns within 24 hours
- Symptoms resolve within days or weeks
- Most common form of mild TBI is a concussion
- Medical care isn't typically needed, but they should rest and be monitored
- Seek medical attention if symptoms worsen
Moderate
- GCS score: 9-12
- Unconsciousness lasts more than 30 minutes but less than 24 hours
- Trouble speaking or communicating
- Partial paralysis
- Problems with thinking and memory
- Memory loss can last up to a week
- Immediate medical care is needed to reduce the risk of further damage
Severe
- GCS score: 8 or less
- Loss of consciousness for six hours or more
- Much higher risk of long-term complications or death
- Require ongoing medical care
What are the symptoms of TBI?
Symptoms of a TBI depend on the severity of the injury and can affect thinking, physical abilities, emotions and sleep.
“A moderate to severe injury will have headaches, muscle weakness, coordination and balance problems, decline in memory and cognition, confusion and agitation,” Siu said. “A mild injury commonly presents with dizziness, headaches, fatigue, difficulty concentrating and sensory issues."
Symptoms of mild TBI
- Headache
- Confusion
- Lightheadedness or dizziness
- Blurred vision
- Ringing in the ears (tinnitus)
- A bad taste in the mouth
- Changes in sleep (sleeping more or less than usual)
- Behavior or mood changes
- Trouble with memory, concentration, attention or thinking
- Brief loss of consciousness (seconds to minutes)
- Sensitivity to light or sound
- Nausea or vomiting
Symptoms of moderate or severe TBI
Patients with a moderate or severe TBI may experience some of the same symptoms as a mild TBI, plus:
- Headache that gets worse or will not go away
- Loss of vision in one or both eyes
- Repeated vomiting or continued nausea
- Slurred speech
- Convulsions or seizures
- Inability to wake up from sleep
- Enlargement of the pupil (dark center) of one or both eyes
- Numbness or tingling of arms or legs
- Uncoordinated or "clumsy" movements
- Increased confusion, restlessness or agitation
- Loss of consciousness lasting minutes to hours
Anyone who suffers a blow to the head should seek medical attention quickly even if symptoms aren't present. Symptoms might not appear right away, so it's important to be evaluated.
Who is at higher risk of TBI?
There were 69,000 TBI-related deaths in 2021, according to the CDC, with falls accounting for nearly half of TBI-related hospitalizations. Anyone can have a TBI, but some groups are at a higher risk of injury or complications.
Higher risk of having a TBI
- Young children: Adolescents are still developing motor skills and balance. The brain is still developing, which may increase risk of long-term effects.
- Adults over age 65: The risk of falling increases with age meaning an increased risk of TBI. Reducing the risk of a fall means reducing the risk of TBI.
- Student athletes: Younger athletes between the ages of 15-24 are at a greater risk, particularly in contact sports like football, hockey and rugby.
- People in dangerous or high-risk jobs: This includes construction, law enforcement, military, transportation and similar fields.
- Veterans and active-duty service members
- Victims of violence
Higher risk of long-term complications
Some groups may not only be at a higher risk of TBI, but also of worse outcomes due to barriers in health care. These include:
- Racial and ethnic minorities
- Service members and veterans
- People experiencing homelessness
- People in correctional and detention facilities
- Survivors of domestic violence
- People living in rural areas with limited access to care
What are the effects of TBI?
The brain is the body’s command center. It receives information from the five senses (vision, smell, touch, taste and hearing) and sends signals to the body directing the response. It controls thought, memory, emotion, touch, motor skills, vision, breathing, temperature, hunger and other processes. When brain cells are damaged, the brain can't send and receive information normally. This can lead to changes in thinking, movement, behavior and physical health.
Cognitive changes (thinking and memory):
- Short-term memory loss
- Shortened attention span
- Difficulty with problem-solving and following directions
- Partial or complete loss of reading and writing skills
- Poor judgment
- Communication problems, including loss of vocabulary
- Difficulty learning new things or understanding concepts
Physical changes:
- Weakness in part of the body
- Poor coordination
- Swallowing difficulties
- Changes in vision, hearing, touch and taste
- Paralysis and immobility
- Seizures
- Sleep issues
Behavioral and personality changes:
- Trouble with social skills
- Inability to empathize
- Tendency to be more self-centered
- Inability to control emotions
- Irritability, frustration or being easily angered
- Inappropriate or aggressive behavior
- Extreme mood swings
- Depression
Can you recover from TBI?
Many patients with TBI do improve, especially with early treatment and rehabilitation. However, recovery looks different for everyone.
How long does TBI recovery take?
Factors such as the severity of the injury, overall health, access to therapy and the support system at home all play a role. Because of this, there is no single, predictable timeline for recovery.
"Patients often ask, 'when can I go back to work?' and 'when can I go back to driving?' I always discuss these questions with the patient and caregivers, so they know returning to these things will be a step-by-step progression," Siu said.
Clinicians like Dr. Siu typically see the most improvements during the first six months after the injury. During this time, the brain is at a heightened state of plasticity, meaning it is actively healing and forming new connections.
How is TBI treated in inpatient rehabilitation?
After a traumatic brain injury, your doctor might recommend inpatient rehabilitation. This level of care brings together a team of therapists and doctors to develop a personalized care plan to help patients regain function, independence and safety.
In an inpatient rehabilitation hospital:
- Patients receive intensive therapy three hours a day, five days a week
- Registered nurses, many specialized in rehabilitation care, are available 24/7
- Rehabilitation physicians meet with patients frequently
"Our care teams consist of physical therapists, occupational therapists, speech-language pathologists, case managers, dietitians, pharmacists and neuropsychologists," Siu said.
Each patient is also assigned a case manager, who helps prepare the patient and family for the next steps in recovery and connects them to community resources.
There is also an onsite pharmacist to help with medications, and dietitians can assist with special dietary needs.
These experts work together for a common goal — restoring the patient's highest possible level of independence.
Physical therapy
Physical therapy (PT) helps patients rebuild physical strength, mobility and balance after a TBI. "This varies depending on the situation and patient, but most goals will be functional," said Joseph Jameson, a senior physical therapist at Encompass Health Braintree. This includes walking, standing and moving parts of the body.
For TBI patients, physical therapy goals include increasing strength, balance, endurance and functionality. Therapy prioritizes safety, both in inpatient rehabilitation and the patient's home environment.
"The plan of treatment is adjusted. We give them strategies to maintain control and evaluate situations to increase safety. It's important that families are educated and taught how to properly keep a patient safe if they have the inability to make decisions on their own," Jameson said.
Occupational therapy
Occupational therapy (OT) helps patients improve or adapt their ability to perform activities of daily living (ADLs) such as dressing, bathing, toileting and grooming. This type of therapy complements progress in physical therapy and can extend beyond basic activities into instrumental activities of daily living (IADLs) such as managing medications, grocery shopping and managing money.
Ashley Henriksen, an occupational therapist at Encompass Health Braintree, describes the individual nature of OT:
"There are a vast variety of ways a brain injury can affect a patient. We base our goals on information given to us about how they were functioning in the community prior to brain injury and the deficits it caused. For example, a patient with a mild TBI who was accustomed to an independent lifestyle before injury would work on upper extremity function and learn modified techniques for getting dressed if they experience weakness on one side of their body."
For a more severe TBI, occupational therapists focus on patients' basic interaction with their environment. "Moderate to severe TBI patients may have deficits in language, cognition, sensation, balance and vision. In those cases, we work on identifying and using functional objects and ADL retraining," Henricksen said.
Speech therapy
Speech therapy after brain injury focuses on much more than speech. It includes the function of mechanisms above the base of the neck.
"From a speech perspective, speech therapists primarily look at speech, language, cognition and swallowing for TBI patients," said Moriah Baker, a speech-language pathologist at Encompass Health Braintree.
Speech therapy may address:
- Managing swallowing issues (dysphagia)
- Improving slurred speech (dysarthria) through posture, pacing and articulation
- Reading and understanding written information
- Functional math tasks, such as online banking
- Recall exercises using pictures, words or stories
- Sequencing tasks (the order of doing certain things)
Caregivers and TBI
Caregivers often struggle with exhaustion, stress, depression and even anger when caring for someone recovering from a TBI. It's important to ask for help and take breaks. In inpatient rehabilitation, case managers connect families to support such as:
- Education and training from the care team
- Home health aides and personal assistants to allow for caregivers to take breaks
- Support groups to connect with others in similar circumstances
- Long-term therapy to help adjust to changes and establish coping skills
- Online resources, books and other materials to educate caregivers